CardioBrief: Salt Restriction Harmful in HF?

Study raises more questions, still without good answers

Sodium restriction is a cornerstone of heart failure management, but many people would be surprised to learn that there is no good supporting evidence for the practice. Now a new observational study raises further questions about sodium restriction in heart failure.

In a paper published in the Jan. 1 issue of JACC: Heart Failure, researchers from Rush University Medical Center sought to assess the impact of sodium restriction, which was tracked by serial food frequency questionnaires, on outcomes in 833 heart failure patients who participated in the HF Adherence and Retention Trial (HART).

The authors wrote that their "findings support further downgrade of the American College of Cardiology Foundation/American Heart Association sodium restriction recommendation in patients with chronic HF to class IIb (efficacy less well established, conflictive evidence), and press the need for multicenter randomized trial to definitively address the role of sodium restriction in HF management."

In an accompanying editorial comment, Scott Hummel, MD, and Matthew Konerman, MD, both of the University of Michigan in Ann Arbor, acknowledged the study's limitations but recommended that the current guidelines "should be taken with a grain of salt."

"Considering the challenge this restriction poses for patients, it is even more important to clarify whether sodium restriction is beneficial at all," they wrote.

In a second editorial comment, Clyde Yancy, MD, of Northwestern University and past president of the AHA, pointed out that the "traditional logic" supporting sodium restriction "has been so clear that to call for proof seemed heretical. Yet, an exhaustive search of available literature does not provide evidence."

"The current study," he continued, "adds to the momentum to call the question but does not provide answers."

Asked to comment on the paper, Milton Packer, MD, of Baylor University in Dallas, sent the following statement:

"I am not certain what we are supposed to do with these data. A retrospective analysis of the association of reported (not confirmed) sodium intake and various outcomes is not a particularly useful piece of evidence. Should we dismiss the findings entirely? Should the findings lead us to question our core recommendations regarding sodium restriction? How is one supposed to know? These data do not help clarify the situation at all.

"We have had no basis for any of our recommendations regarding sodium restriction during the past 50 years, although these recommendations have changed a great deal (for no good reason). After this report, we still have no basis for any of our recommendations regarding sodium restriction. We were ignorant before; we are not any smarter now. Did we really need this report to tell us that we lack evidence for our recommendations regarding dietary sodium in patients with heart failure?"

Salim Yusuf, MD, DPhil, of McMaster University in Hamilton, Ontario, told CardioBrief that he fully concurred with the authors and commenters that "we need definitive randomized trials of whether extreme lowering of sodium is helpful, safe or useless." He continued:

"The growing body of evidence from epidemiologic studies is consistent in not showing any clinical benefit with lower sodium intakes below 4 g per day in several different populations: healthy free living, e.g., the PURE study; those with vascular disease, e.g., in ONTARGET; in diabetics; and now in heart failure.

"Surely guidelines cannot keep on ignoring the collective weight of evidence that very low sodium consumption is associated with worse outcomes. Of course, epidemiologic studies cannot necessarily indicate whether the excess events with low sodium is causal. The only way forward is to conduct a series of randomized controlled trials to examine the impact of extreme lowering of sodium in several different populations where lowering sodium is being recommended.

"While such trials are underway, it would be prudent to stop recommending extreme lowering of sodium (say below 3 g of sodium per day) as one cannot exclude harm and there is no evidence of benefit.

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